FICTIONAL BEHAVIORAL-HEALTH RELEASE SAMPLE — NOT A PATIENT RECORD OR AUTHORIZATION — DO NOT SIGN OR SUBMIT
Rosebridge Counseling Center · rosebridge.example
Behavioral Health & Therapy
72 Rosebridge Way, Cedarwick, EX 01001 · (555) 010-0162 · privacy@rosebridge.example
Form DEMO-NOT-FILED-MHR-0518 Fictional Records Layout
SAMPLE-DATE

Authorization to Disclose Behavioral Health Records

Confidential · HIPAA 45 CFR §164.508 · Held in trust
1
Client InformationThe person whose records are being released
Client name
SAMPLE CLIENT
Date of birth
SAMPLE-DOB
Record / file #
SAMPLE-RECORD
Address
100 Sample Lane, Cedarwick, EX 01001
Phone
(555) 010-0244
2
Release DirectionFrom your current office, to the receiving provider
Released by
Provider / office
Rosebridge Counseling Center · rosebridge.example
Address
72 Rosebridge Way, Cedarwick, EX 01001
Phone / fax
(555) 010-0162 / fax (555) 010-0163
Disclosed to
Receiving provider
Pinehaven Behavioral Review — Fictional Recipient
Address
120 Sample Way, Pinehaven, EX 01002
Phone / fax
(555) 010-0481 / fax (555) 010-0482
3
Records to ReleaseCheck the items you authorize Rosebridge to share
Treatment summaryCourse of care, goals, outcomes
Progress notesSession notes documenting treatment
Diagnosis / assessmentIntake assessment, diagnoses
Treatment / care planCurrent goals and interventions
Medication recordPsychiatric medication list
Billing / statementsItemized account history
Other (specify):Discharge / transfer-of-care letter
Psychotherapy notes — extra protection Separate consent
Under HIPAA, the therapist's private psychotherapy notes — the personal notes kept separate from your main record — receive special protection and are never released by a general authorization. To include them, you must give your own separate, explicit consent here. You may leave this unchecked and still release everything above.
I specifically authorize the release of psychotherapy (process) notes to the provider named above. Initial
Records dated SAMPLE-STARTthroughSAMPLE-END or entire record
4
Purpose & Expiration
Purpose of disclosure
Continuing care / transfer of care Coordination with provider Personal use Other
Notes
Transfer of care to a new therapist
This authorization expires
SAMPLE-EXPIRATION
Illustrative field only. This sample creates no authorization period or rights.
Your rights & consent
  1. You may revoke this fictional authorization at any time by writing to Rosebridge Counseling Center. It is an example only and cannot authorize disclosure.
  2. Your care is not conditioned on signing. This fictional example does not represent a provider or treatment relationship.
  3. Re-disclosure. Once your records reach the receiving provider, they may no longer be protected by HIPAA and could be re-disclosed by that provider.
  4. Copies. You are entitled to a copy of this signed authorization; a copy is as valid as the original.
I have read and understand this authorization, and I am signing it freely and voluntarily to share the records I have marked, with the provider I have named, for the purpose I have stated.
5
Signature
SAMPLE SIGNATURE — NOT VALID
Signature of client
SAMPLE-DATE
Date
SAMPLE CLIENT
Printed name
SAMPLE-DOB
Date of birth
Complete only if a personal representative is signing on the client's behalf (legal guardian or health-care power of attorney).
Signature of personal representative
Relationship / authority to act
Date
Rosebridge Counseling Center · rosebridge.example · FICTIONAL EXAMPLE — NOT A MEDICAL RECORD Fictional Behavioral Health Records Layout · DEMO-NOT-FILED · Page 1 of 1